A Clinical Documentation Specialist is a healthcare professional who is responsible for maintaining and ensuring the accuracy of medical records. They also work towards making sure that the documentation aligns with the coding guidelines and legal requirements.
Clinical Documentation Specialists work in various healthcare institutions, including hospitals, clinics, and health departments. Their main duty is to review and verify the patients' medical records and make sure they are complete. They also ensure that these records can be easily understood and follow the required standards.
With increasing emphasis on data and records in healthcare, Clinical Documentation Specialists are in high demand. There are opportunities to work in diverse healthcare settings, with interesting roles and potential for professional growth and progression.
RN Specialist, Clinical Documentation - MUST Reside in Colorado
$82K - $127K *
Join a team that's committed to enhancing healthcare by ensuring accurate clinical documentation and fostering collaboration among medical professionals to support quality patient care and compliance...
Reposted 1 week ago
Senior Clinical Documentation Integrity Specialist
$75K - $95K *
Contribute to improving clinical documentation integrity through developing standard processes, educating staff, and conducting thorough reviews to enhance compliance and support value-based care init...
3 days ago
Clinical Documentation Specialist (Remote -Texas Resident) - Clinical Data
$71K - $115K *
Grow your career with a role focused on enhancing clinical documentation quality and accuracy, facilitating collaboration across healthcare teams, and improving patient data representation to support...
3 weeks ago
Clinical Documentation Auditor and Educator
$96K - $134K *
Support and enhance clinical documentation integrity processes by evaluating reviews and compliance. Collaborate with the CDI team to provide coaching, develop educational resources, and deliver insig...
Reposted 2 weeks ago
RN Clinical Documentation Integrity Specialist - Remote
$75K - $95K *
Unlock potential by leading clinical documentation reviews and enhancing healthcare quality. Collaborate with teams to ensure accurate representation of patient care and support optimal reimbursement...
1 week ago
RN Educator, Clinical Documentation Integrity - Must Reside in Colorado
$85K - $132K *
Help us enhance clinical documentation quality through education, collaboration, and audits, impacting patient care outcomes. This role involves training, compliance reviews, and teamwork across depar...
Reposted 2 weeks ago
$75K - $95K *
Play a key role in clinical reviews by assessing medical necessity of healthcare services, collaborating with interdisciplinary teams, and ensuring compliance with quality standards through detailed d...
3 weeks ago
DRG Validation Auditor (Clinical & Coding)
$95K *
Lead inpatient auditing efforts focusing on clinical chart validation and coding accuracy, using advanced ICD-10 knowledge to independently analyze claims, ensure compliance, and enhance auditing proc...
3 weeks ago
Auditor Clinical Validation Outpatient Specialty Clinical
$95K *
Explore a dynamic role auditing outpatient and specialty claims, ensuring coding accuracy and compliance while applying clinical expertise. Contribute to process improvement and collaborate effectivel...
2 weeks ago
Auditor Clinical Validation OPSP Coding
$95K *
Unlock potential in outpatient and specialty audits by leveraging clinical and coding expertise. Conduct thorough claim audits, ensuring accuracy, compliance, and identifying improvement opportunities...
2 weeks ago
SVP, Quality, Risk Adjustment, & Documentation
$250K - $330K *
Drive excellence in quality, risk adjustment, and documentation, integrating critical functions to improve payer performance and financial sustainability in value-based care. Lead a transformative str...
6 days ago
$70K - $126K *
Lead the charge in ensuring accurate MS-DRG and APR-DRG coding while exercising autonomy in clinical documentation reviews. Collaborate with medical experts to optimize compliance and enhance reimburs...
Reposted 4 days ago
Manager of Inpatient Coding Auditing & Education
$90K - $120K *
Champion comprehensive inpatient coding audits and education initiatives, ensuring compliance and performance improvement within a dynamic healthcare environment, with leadership responsibility for a...
2 weeks ago
Configuration Management / Documentation Specialist
$75K - $95K *
Manage configuration management processes to ensure compliance and traceability across Air Force IT systems. Collaborate with cross-functional teams to maintain documentation, support CI/CD pipelines...
2 weeks ago
Region Manager Revenue Cycle Coding-CDI Audit - Educ-CentNWSo
$90K - $120K *
Transform the coding and CDI landscape by leading audit and education initiatives, ensuring compliance and enhancing performance across teams. Drive training development and process improvement to fos...
5 days ago
Manager, Clinical Quality Operations
$90K - $100K *
Champion excellence in clinical operations by managing field practitioners, ensuring compliance and quality care, and driving operational success in a dynamic healthcare environment. Lead innovative t...
Yesterday
Coding Auditor & Educator Lead
$75K - $95K *
Lead the coding audit and education operations, managing personnel, facilitating training, and ensuring standardization across the region, driving quality and productivity in healthcare coding service...
2 weeks ago
Epic Certified Clinical Inpatient (ClinDoc) Analyst 5944597
$93K - $104K *
Elevate your career by managing applications and driving day-to-day operations. Collaborate with stakeholders and offshore teams to enhance support in a dynamic healthcare environment while ensuring c...
4 weeks ago
$83K - $93K *
Shape the future of healthcare through enhanced clinical documentation quality, ensuring thorough medical records and accurate coding. Collaborate with providers to elevate patient care and compliance...
Yesterday
$75K - $103K *
Contribute to the development of clinical coding by analyzing medical policies, ensuring high quality and relevance while mentoring team members in a dynamic environment. Collaborate with various team...
1 week ago
Epic Inpatient ClinDoc/Stork Analyst
$80K - $110K *
Pioneer the optimization of inpatient clinical applications, collaborating with end-users and operational leaders to enhance workflows and support Epic EHR systems. Drive impactful communication and a...
2 weeks ago
Clinician Coding Liaison - Surgery
$73K - $110K *
Explore the complexities of coding for surgical and complex specialties by providing education, support, and documentation feedback. Collaborate across departments to optimize workflows and ensure com...
5 days ago
Coding Coordinator IV - (Remote)
$68K - $109K *
Take ownership of accurate coding and documentation processes in inpatient care. Lead coding teams to enhance quality and compliance while ensuring efficient operations aligned with industry best prac...
Reposted today
$80K - $84K *
Elevate healthcare delivery by conducting comprehensive medical claims reviews, ensuring accurate coding and pricing determinations. Collaborate with multi-disciplinary teams to enhance coding process...
6 days ago
$120K - $145K *
Empower the health plan as a Medical Policy Director, guiding coding and payment policy strategies while collaborating with diverse teams to optimize client solutions and deliver impactful presentatio...
1 week ago
What is a Clinical Documentation Specialist?
A Clinical Documentation Specialist is a healthcare professional responsible for the accuracy and completeness of medical records. They ensure these records meet coding guidelines and legal requirements.
Where can Clinical Documentation Specialists work?
Clinical Documentation Specialists work in a variety of healthcare settings such as hospitals, clinics, and health departments.
What is the average salary for Clinical Documentation Specialist jobs?
The average salary can vary depending on the location and the company. However, on Ladders, you can find Clinical Documentation Specialist jobs that pay over $100000.
What qualifications do I need to become a Clinical Documentation Specialist?
Typically, a Clinical Documentation Specialist requires a degree in health informatics or a similar field and some prior experience in a healthcare setting. Further, professional certification may enhance job prospects.